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)ry , -. .. .,-.pqngv;N:nFil•�I;OP,.A'�".it".'• '`Hr. <br /> STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �a <br /> SIT <br /> JE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION °< <br /> C' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> o Laz rro <br /> ADDRESS NEAREST CROSS STREET ✓ggWP ordim D PARTNERSHIP 0 STATE AGENCY <br /> L9�CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> Q.0 1 L Ue . — Robirlhooct D INDIVIDUAL D cour -Amoy G <br /> CITY N STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> r✓ CA a o a o9 5� � Y <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or tt , #of TANK's <br /> ❑ t GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ /V 0 �� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Robert 'Romern do S- 9 <br /> NIGHTS: NAME(LAST,FIRST) PHON #WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> m� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS YJFORMATION <br /> f' &Scciafes <br /> MAILING or STREET ADDRES ✓ xto i,dicale D PARTNERSHIP Cl STATE-AGENCY <br /> LSI CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> b A Ra hooet P r. D INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME C, STATE ZIP CODE PHONE p WITH AREA CODE <br /> •-} 't7S- <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL rg III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> 39 10Dlaaa 1 101010131 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> _'henws7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS <br /> TRACCT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ©� � Jr 8D ��� YES NO Tot 88 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-BB) - <br /> DATA PROCESSING COPY 5 <br />